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The Skin and Subcutaneous Tissue (INJURIES (Caustic Injury (2.4-10.7% of…

- - - - Clean lacerations:
        may be closed primarily after irrigation, debridement, and exploration.
        (Many primarily close clean wounds if injury treated within 6 hrs of inciting event; however no systematic evidence regarding timing of closure; :question: why should time matter?)
        
        Contaminated or infected:
        heal by secondary intention or delayed primary closure
      - Tangential abrasions: management dependent on depth of injury
        
        Superficial partial-thickness wounds:
        heal spontaneously + topical antimicrobial prophylaxis or sterile biologic dressings.
        
        Deeper wounds:
        
        split-thickness skin grafting to avoid prolonged need for dressing changes & hypertrophic scarring
        
        Degloved skin: coverage similar to a skin graft, or as a temporary dressing, provided wound bed cleaned.
    - - Bite bacteriology: normal mouth flora + content of offending animal’s food
        
        Early presentation bite wounds--> polymicrobial cultures
        
        Common aerobic: Pasteurella multocida, Strep, Staph, Neisseria, and Corynebacterium;
        
        anaerobic: Fusobacterium, Porphyromonas, Prevotella, Propionibacterium, Bacteroides, and Peptostreptococcus.
        
        Capnocytophaga canimorsus: rare after a dog bite; immunocompromised pxs most susceptible to this infection
        
        Late presentation bite wounds--> single organism type
        
        load in dog bites heavily dependent on content & timing of last meal
        spectrum in cat bites very similar to that of dogs, w/ a slightly higher prevalence of Pasteurella ; Rare infections from cats: Francisella tularensis (tularemia) and Yersinia pestis (human plague).
      - human bites bacteria: on skin or in mouth
        G+ aerobic: Staph aureus, Staph epidermidis, Strep
        anaerobes: G+: Peptococcus & Peptostrep, G-: Bacteroides & Eikenella corrodens (a facultative anaerobe)
        --> Antibiotic must cover G+ & anaerobic:
        
        A first-gen cephalosporin [ex cephazolin more on G+ than negative, also doesn't effect anaerobes (G+ or G-)] w/ penicillin or ampicillin [cover G+ aerobes and anaerobes but not G- anaerobes (bacteroides) bc of beta-lactamase production)] in combination w/ clavulanic acid [a beta lactamase inhibitor]
        
        Clindamycin an alternative, but additional coverage for Eikenella corrodens needed
      - standard wound care:
        Irrigation (preferably w/ sterile saline solution):
        :question: (pulse/nonpulse; pressure/superficial)
        
        reduce surface bacteria only if done w/ nonpulsatile irrigation.
        
        to significantly reduce bacterial load and eliminate particulate debris in wound: pressure irrigation
        
        80% of wounds presenting to emergency department have a bacterial load <105 --> superficial irrigation suffice.
        
        Larger wounds w/ signs of infection--> pulse irrigation
        
        Rapid quantitative cultures guide treatment in suspected infection.
        Human bites charac higher bacteria load (>105)
      - select cases: bite wounds may be closed primarily, partic in areas of aesthetic significance (ex face) where secondary intention healing--> scarring; should follow initial management as outlined earlier, along w/ close follow-up to permit early detection of infection